PHCL 471
Nouf M Aloudah
Functional Elements Of Clinical
Pharmacy Practice
• Clinical pharmacy have evolved and still evolving in a variety of ambulatory and institutional pharmacy settings
• Many hospitals now providing medication histories, patient drug counseling, patient drug monitoring, and drug information services
• Specialized clinical services such as clinical pharmacokinetics, nutritional support, clinical toxicology
Functional Elements Of Clinical
Pharmacy Practice
Historical development of clinical pharmacy
• Definitions of clinical pharmacy:
▫ Clinical pharmacy practice as a practice in which the pharmacist utilizes his professional judgment in the application of pharmaceutical sciences to foster the safe and appropriate use of drugs, in or by patients, while working with members of the health care team
Functional Elements Of Clinical
Pharmacy Practice
Historical development of clinical pharmacy
• Definitions of clinical pharmacy:
▫ American Association of Colleges of Pharmacy : clinical pharmacy is that area within the pharmacy curriculum which deals with patient care with emphasis on drug therapy. Clinical pharmacy seeks to develop a patient oriented attitude. The acquisition of new knowledge is secondary to the attainment of skills in inter-professional and patient communication
Functional Elements Of Clinical
Pharmacy Practice
Historical development of clinical pharmacy
• Definitions of clinical pharmacy:
▫ Others: the primary mission of clinical pharmacy is the promotion and assurance of rational and safe drug therapy, the other health care practitioners share this goal with clinical pharmacists, though this is not their sole, intensive concern!
Functional Elements Of Clinical
Pharmacy Practice
Historical development of clinical pharmacy
• Definitions of clinical pharmacy:
▫ Clinical pharmacy is a health science specialty whose responsibility is to assure the safe and appropriate use of drugs in patients through the application of specialized knowledge and function in patient care, and which necessities specialized education and/or structure training. It requires use of judgment in the collection and interpretation of data, patient- specific involvement, and direct inter-professional interactions
Functional Elements Of Clinical
Pharmacy Practice
Historical development of clinical pharmacy
• Definitions of clinical pharmacy:
▫ In summery clinical pharmacy involves the application of drug knowledge on behalf of the patient, while considering the patient’s disease conditions and his need to understand drug therapy
▫ The practice requires a close association between the pharmacy and the patient, physician, and other providing health care services
Functional Elements Of Clinical
Pharmacy Practice
Historical development of clinical pharmacy
• Factors influencing the development of clinical pharmacy:
1.
Unresponsiveness of health care delivery system to public needs
2.
Absence of a single discipline with broad responsibility for drug use control
3.
Overeducated and underutilized pharmacists
4.
Diminished demand for the traditional compounding skills of pharmacists
5.
Major unresolved problems with drug use in society
6.
Inadequate drug knowledge on the art of health professionals and patients
Functional Elements Of Clinical
Pharmacy Practice
Historical development of clinical pharmacy
• Factors influencing the development of clinical pharmacy:
▫ In the past, the pharmacist has often isolate himself from the patient and from other health practitioners
▫ The health professions are now facing the problem of how to design a health care system which will provide health maintenance for all people at the most reasonable cost
▫ It is becoming clear that such a system will depend on close cooperation among all health professions
▫ Clinical pharmacy stands to play a major role in the attainment
Functional Elements Of Clinical
Pharmacy Practice
Historical development of clinical pharmacy
• Factors influencing the development of clinical pharmacy:
▫ All of the health disciplines have involved to some degree with drugs, but no particular discipline has exercised a broad responsibility for the total drug use process
▫ This resulted I drug misuse, overuse, abuse and in serious unwanted drug effects
Functional Elements Of Clinical
Pharmacy Practice
Historical development of clinical pharmacy
• Factors influencing the development of clinical pharmacy:
▫ All of the health disciplines have involved to some degree with drugs, but no particular discipline has exercised a broad responsibility for the total drug use process
▫ This resulted In drug misuse, overuse, abuse and in serious unwanted drug effects
▫ Led to the thinking that there was a need for one discipline to assume broad leadership and responsibility for the safe and appropriate use of drugs in society
Functional Elements Of Clinical
Pharmacy Practice
Historical development of clinical pharmacy
• Factors influencing the development of clinical pharmacy:
▫ 1960s recognized that most pharmacist were overeducated!
▫ The climate was right for a major change in pharmacy practice
Functional Elements Of Clinical
Pharmacy Practice
Historical development of clinical pharmacy
• Factors influencing the development of clinical pharmacy:
▫ Educators and practitioners began to press for change in pharmacy practice and education
Functional Elements Of Clinical
Pharmacy Practice
Clinical pharmacy functions and services
Includes one or more of those activities as general or specialized
General clinical pharmacy functions and services
• Providing drug information to other health professionals
• Aimed to
• Defining therapeutic goals and endpoints of drug therapy
• Selecting the most appropriate therapeutic agent for drug therapy
• Prescribing the most appropriate drug regimen
• Monitoring the effect of drug therapy based upon indices of effect and
• Selecting methods for drug administration
Functional Elements Of Clinical
Pharmacy Practice
General clinical pharmacy functions and services
▫ Significant improvement
▫ Drug information and poison centers
Functional Elements Of Clinical
Pharmacy Practice
General clinical pharmacy functions and services
▫ Obtaining patient medication histories and using patient medication profiles to assure proper drug utilization
Minimum it should contain ………
Additional drug specific monitoring information may be obtained on patient files
Functional Elements Of Clinical
Pharmacy Practice
General clinical pharmacy functions and services
▫ Monitoring drug therapy
▫ Effectiveness, ineffectiveness, ADR, toxicity ect
▫ Food and drug administration adverse reaction reporting programs
▫ Medication profile, laboratory data, physical examination data, nurses’ and physicians’ notes and even the results of ECG, X ray are used monitor drug therapy response
Functional Elements Of Clinical
Pharmacy Practice
General clinical pharmacy functions and services
▫ Providing patient education and medication counseling
Functional Elements Of Clinical
Pharmacy Practice
General clinical pharmacy functions and services
▫ Providing disease screening, monitoring, and maintenance care for patients with chronic diseases
Functional Elements Of Clinical
Pharmacy Practice
General clinical pharmacy functions and services
▫ Participation in the management of emergency medical care
Functional Elements Of Clinical
Pharmacy Practice
General clinical pharmacy functions and services
▫ Serving as a health information and education source for the public
Functional Elements Of Clinical
Pharmacy Practice
General clinical pharmacy functions and services
▫ Participation in drug use review and patient care audits
Functional Elements Of Clinical
Pharmacy Practice
General clinical pharmacy functions and services
▫ Providing in-service education for physician, nurses, and other health professionals
Functional Elements Of Clinical
Pharmacy Practice
Specialized functions and services:
▫ Nutritional support services
▫ Formal (written) drug therapy consultations
▫ Clinical pharmacokinetics services
▫ clinical toxicology services
▫ Clinical drug investigations
Functional Elements Of Clinical
Pharmacy Practice
• Franck’s legacy40 years of clinical pharmacy
• clinical pharmacy 30 years later !
• clinical pharmacy and medication safety
• scope of international clinical pharmacy
PHCL 471
Nouf Aloudah
Clinical Pharmacy Lecturer
King Saud University
How To Get Involved in Medical Rounds
• Rationale For The Pharmacist’s Participation In
Rounds
A.
IMPROVED PATIENT CARE
1.
Promotion Of Rationale Drug Therapy
1.
Evaluate appropriateness of the selected drug
2.
Calculating the dosage consistent with the renal and hepatic function of the patient
3.
Determining an acceptable dosage interval that will ensure therapeutic benefit and compliance
4.
Preventing drug related adverse effects
How To Get Involved in Medical Rounds
• Rationale For The Pharmacist’s Participation In
Rounds
2.
Provision Of Drug Information
How To Get Involved in Medical Rounds
• Rationale For The Pharmacist’s Participation In
Rounds
B.
EDUCATION OF THE PATIENT AND THE
HEALTH CARE TEAM
1.
Educating and interacting with the patient
2.
Educating the pharmacist
3.
Educating other health professionals
4.
Educating patients and hospital staff about pharmacy services
How To Get Involved in Medical Rounds
• Types Of Rounds
▫ Medical teaching service rounds
▫ Private physician rounds
▫ Special unit rounds
▫ Interdisciplinary rounds
▫ Pharmacy rounds
How To Get Involved in Medical Rounds
• Factors In The Pharmacist’s Selection Of a
Rounding Team
▫ Time available
▫ Ability to work with the physician
▫ Continuity of patient care
▫ Personal interests
▫ Acceptance by the rounding team
How To Get Involved in Medical Rounds
• Pharmacist’s Preparation For Rounds
A.
Self preparation
Become familiar with appropriate references
Keep abreast of current research
Determine appropriate patient monitoring criteria
Understand and maintain the rounding schedule
How To Get Involved in Medical Rounds
• Pharmacist’s Preparation For Rounds
B.
Specific Planning
Develop a monitoring profile and/or patient log sheet
Determine the best method for communicating with the rounding team
Reassess specific drug therapy periodically
Prepare lectures on related drug topics
Work out a system where you can be contacted readily
Make certain that other pharmacists and supportive personnel understand what you are doing
How To Get Involved in Medical Rounds
• Pharmacist’s Preparation For Rounds
C.
Preparation of specific monitoring aids and a daily rounding checklist
PHCL 471
Nouf M Aloudah
Clinical Pharmacy Lecturer
College of pharmacy
King Saud University
Monitoring Drug Therapy
• most important clinical function of the pharmacist
Monitoring Drug Therapy
• is a process which encompass all those functions necessary to ensure appropriate, safe, efficacious and economical drug therapy to the patient
• functions
Monitoring Drug Therapy
• Rationale
• literature identified some significant problems with regards to the drug therapy of patients due to increasing no of available drugs
• problem includes…
Monitoring Drug Therapy
• Use Of Medical Records
• you should be familiar with patients medical records
• types of patient records
▫ the source oriented record
▫ the problem oriented record
data base section
problem list
plan
progress notes
discharge summery
Monitoring Drug Therapy
• Setting Priorities
• do not have staff to be able to monitor each and every patient receiving drug therapy
• at risk of developing adverse effects from drug therapy should be identified
▫ patient selection by disease state
▫ patient selection by drug therapy
Monitoring Drug Therapy
• The Process Of Monitoring Drug Therapy
A.
problem orientation off patient data
Monitoring Drug Therapy
• The Process Of Monitoring Drug Therapy
B.
determination of the appropriateness of specific therapy
Monitoring Drug Therapy
• The Process Of Monitoring Drug Therapy
C.
development of specific therapeutic goals
Monitoring Drug Therapy
• The Process Of Monitoring Drug Therapy
D.
development of specific monitoring parameters
Monitoring Drug Therapy
• The Process Of Monitoring Drug Therapy
E.
identification of problems
Monitoring Drug Therapy
• The Process Of Monitoring Drug Therapy
F.
development of alternatives or solutions to problems
Monitoring Drug Therapy
• The Process Of Monitoring Drug Therapy
G.
communication of findings and recommendations
Monitoring Drug Therapy
• Developing A Plan Of Self Study
PHCL 471
Nouf M Aloudah
Clinical Pharmacy Lecturer
College of Pharmacy
King Saud University
Teaching And Counseling Patients
About Drugs
Introduction
• Practiced several years and years
• Innovative ways
• Limited by financial constrains and the willingness of pharmacists to participate in this activities
• Understanding the need is basic for designing quality programs
Teaching And Counseling Patients
About Drugs
• Who should teach and counsel?
▫ Not drug information you want to change behavior
▫ Noncompliance occur in 30-50%
▫ Oral or written intervention by the pharmacist improved compliance
Teaching And Counseling Patients
About Drugs
• Who should teach and counsel?
▫ Physician?
First to see pt
They remember 20-40 of what been told to them
Multiple demands on them
Teaching And Counseling Patients
About Drugs
• Who should teach and counsel?
▫ Nurse?
Happened in many institutions
Identify it to prevent duplication
Approached positively they will welcome
Provide educational material
Administer drug daily, it is a good chance!
Teaching And Counseling Patients
About Drugs
• Who should teach and counsel?
▫ Pharmacist?
Last to see the pt
Needs to develop skills
Ethical responsibility
Obtain data to support the program
Teaching And Counseling Patients
About Drugs
• Who should be taught and counseled?
▫ Time and manpower determine who one can teach and what type of educational programs
pt referred by physicians
Pt with specific disease status
Pt receiving specific drug classes
Elderly populations
Pediatric populations
Pt being discharged
Teaching And Counseling Patients
About Drugs
• How to teach and counsel?
▫ Pt education not information
▫ Not only to teach but to negotiate a regimen
▫ Assessment phase
Open ended questions
Reflective questions
Closed ended questions
Suggestive questions
▫ Planning and implementation phase
Verbal communication
Nonverbal communication
listening
▫ Evaluation phase
Teaching And Counseling Patients
About Drugs
• What to teach about drugs?
▫ Major points, helpful to identify which information specific to retain
▫ Drug should be researched toughly prior to session
▫ Planned presentation to ensure covering important points
Teaching And Counseling Patients
About Drugs
• What to teach about drugs?
1. Description and strengths
2. Use and schedule
3. Mechanism of action
4. Effect on life style
5. Storage
6. Potential adverse effects
7. Potential drug or delivery interactions
Teaching And Counseling Patients
About Drugs
• Where to teach and counsel?
▫ Private setting without interruptions
▫ Better recall if counseled in private areas
▫ At least 15 min per session
Teaching And Counseling Patients
About Drugs
• Where to teach and counsel?
▫ Inpatient setting
During hospital stay, at the time of discharge
▫ Outpatient setting
Teaching And Counseling Patients
About Drugs
• Teaching aids?
▫ Printed materials
▫ Audiovisual materials
▫ Compliance aids
▫ Educational display
PHCL 472
Nouf M Aloudah
Clinical Pharmacy lecturer
King Saud University
Providing drug information to health professionals
• Who needs to know what?
• Specific categories of drug information questions and how these questions differs among various types of health professionals
Providing drug information to health professionals
• Drug information categories
• If you know question type you will understand the need, aids in selecting references
Providing drug information to health professionals
Most questions falls into one of the following categories
• Adverse drug reactions
Common side effects to ADR to be reported to FDA
• Ex
▫ Which sedative, …………. Or ……… causes the least amount of hangover?
▫ If the pt allergic to ………. Can we safely administer
………?
▫ Has leukemia ever been associated with the use of …?
Providing drug information to health professionals
Most questions falls into one of the following categories
• availability
Product- oriented questions about old and new drugs
• Ex
▫ Has …. Been released yet?
▫ Who makes …?
▫ What strength doses …. Come in?
Providing drug information to health professionals
Most questions falls into one of the following categories
• Drug interaction
Drug-drug, drug- food, drug- laboratory interactions
• Ex
▫ Can … be used safely with …?
▫ Dose food affect the absorption of …?
▫ Will administering … cause a change in the serum level of …?
Providing drug information to health professionals
Most questions falls into one of the following categories
• Foreign drugs
• Ex
▫ An article about … recently appeared in a British journal. What is it?
▫ A patient recently returned from europ with a Rx of … what its equivalent?
Providing drug information to health professionals
Most questions falls into one of the following categories
• identification
• Ex
▫ What is this tablet?
▫ What are the ingredients in …?
▫ Is an … OTC product?
Providing drug information to health professionals
Most questions falls into one of the following categories
• Pharmaceutical calculations
• Ex
▫ How many mEq of calcium are in 500 mg of …?
▫ How fast should a … drip be run to deliver 5 mcg
/min?
Providing drug information to health professionals
Most questions falls into one of the following categories
• Toxicity and poisoning
Overdose or toxic exposures are in this category
• Ex
▫ what symptoms can be expected in a pt who has taken a bottle of ….?
▫ Should a child who has ingested … receive ipecac?
Providing drug information to health professionals
Needs of health professionals
• Each one may ask any of the question mentioned but each has a different need
• Physicians:
Questions related to prescribing or monitoring drug therapy
• Nurses:
Drug administration, adverse drug reaction
• Pharmacists:
Numerous questions need access to resources
Providing drug information to health professionals
Drug information sources
• Basic drug information reference library
References which contain information on ten categories
• Extent depends on funding
▫ “Must have”
▫ “Should have”
▫ “Nice to have”
Providing drug information to health professionals
• “Must have reference”: tertiary references
(textbooks) five basic types:
1.
Product oriented
2.
Drug oriented
3.
Disease oriented
4.
Specific topic
5.
specialty
Providing drug information to health professionals
• Product- Oriented References
Best source for availability and identification questions
• Ex
▫ Facts and comparison: product monographs, comparative information on similar products, cost index
▫ Handbook of nonprescription drugs: contain monographs on various classes of nonprescription drugs, compare contents of products in similar classes
Providing drug information to health professionals
• Drug- Oriented References
Stronger emphasis on the particular drug or drug class than on the product
• Ex
▫ Martindale, the extra pharmacopeia published every five years, contain extensive referenced monographs on drugs and drug classes with international coverage excellent source for adverse reactions, therapeutic and pharmacology
Providing drug information to health professionals
• Disease- Oriented References
Chapters on disease states, very useful for questions in the therapeutics and pharmacology category from disease perspective
• Ex
▫ Applied therapeutics published every 3-4 years
Providing drug information to health professionals
• Specific topic references
Compatibilities of IV drugs, DI, and poisoning
• Ex
▫ Handbook of injectable drugs
▫ Handbook of poisoning
▫ Applied pharmacokinetics
Providing drug information to health professionals
• Specialty references
Under “should be” references
Providing drug information to health professionals
• a “must have” list would be incomplete without primary references or journals
• Ex
▫ American journal of hospital pharmacy
Providing drug information to health professionals
• Should have “ references
After selection of your “must have” reference the others can be considered “should have”
• Specialty references could be considered “should have”
▫ Cancer chemotherapy
▫ Pediatrics
▫ infectious disease
• At least one journal which discuss drugs and drug therapy
• Ex
▫ The medical letter
▫ pharmacotherapy
Providing drug information to health professionals
• “nice to have” references
Secondary source of drug information
• Ex
▫ Clin -alert
▫ IOWA drug information services
Pharmaceutical manufactures
Providing drug information to health professionals
Answering questions
• Knowing the real question
▫ What the requester actually wants to know, classify the requester (physician, nurse, pharmacist) and obtain the necessary background information
▫ What is the dose of …?possibilities are endless
▫ Patient information: age, weight…, disease condition…, whole medical history ! extent of the question asked
Providing drug information to health professionals
Answering questions
• Systemic search
▫ Which category?
▫ which reference? update?
▫ Not found in tertiary references go to secondary references
Providing drug information to health professionals
Answering questions
• Communicate an answer
▫ Timing ex administration maximum 6 hours
▫ Brief , concise, accurate
▫ Verbally
▫ Sometimes written, should be well organized, grammatically correct, timely manner
Providing drug information to health professionals
Answering questions
• Follow up
▫ When possible with certain types of questions especially directed to pt care
▫ Ex adverse reaction
Providing drug information to health professionals
Answering questions
• As more questions are asked the more confidence will grow
• The key to increase the clinical role is exposure
Providing drug information to health professionals
Drug information support to hospital committee
Participation increase exposure and aids in recognition of our role
• The P & T committee
• It is a policy recommending body, several functions can be supported by DI
• Evaluating drug for inclusion in the hospital formulary
• What to includes?
• Decision is more difficult, keep it simple
Providing drug information to health professionals
Drug information support to hospital committee
• Decision is more difficult, keep it simple
• Educational function of the committee
Providing drug information to health professionals
Drug information support to hospital committee
• DUR
▫ Frequently asked questions may pinpoint areas for which drug use review studies are needed
• Others
▫ Human research committee, infection control committee, nutrition committee
Providing drug information to health professionals
Vehicles for providing drug information
• Pharmacy newsletter
• Provide information and help in pharmacist recognition as drug information source
• Selecting topics:
▫ drug information
▫ P & T committee actions
▫ DUR programs
▫ Journal articles
• Writing for a particular audience
• Publication and disterbution
• Verbal presentation
Providing drug information to health professionals
Vehicles for providing drug information
• Verbal presentation
▫ Formal or informal lectures, in service presentations, ground rounds,
▫ Starts by the pharmacists
▫ Topics
▫ Particular audience
▫ Teaching techniques and strategies: length, formality, objectives, instructional aids, handouts, summery
Providing drug information to health professionals
In summery
• Drug information is a component of all clinical pharmacy services
• Providing DI can be rewarding by
▫ Fully utilized our knowledge
▫ We become more active members of the team
▫ It can open doors to other clinical functions
▫ Achieving rational therapeutics leading to improved pt care
• Best wishes!